Robert B. Doherty

Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper

The U.S. health care system is undergoing a shift from individual clinical practice toward team-based care. This move toward team-based care requires fresh thinking about clinical leadership and responsibilities to ensure that the unique skills of each clinician are used to provide the best care for the patient as the patients needs dictate, while the team as a whole must work together to ensure that all aspects of a patients care are coordinated for the benefit of the patient. In this position paper, the American College of Physicians offers principles, definitions, and examples to dissolve barriers that prevent movement toward dynamic clinical care teams. These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams in organizing the care processes and clinician responsibilities consistent with professionalism.

The Certitudes and Uncertainties of Health Care Reform

The Patient Protection and Affordable Care Act (PPACA) of 2010 was signed into law by President Obama on March 23. This legislation has elicited much debate among policy experts and the public alike. No one knows exactly how this new complex law will play out, and objective evaluation of its effects is important. The American College of Physicians hopes that the legislation will advance key priorities on coverage, workforce, and payment and delivery system reform. The goal of the PPACA is to help provide affordable health insurance coverage to most Americans, improve access to primary care, and lower costs. This article discusses what the chances are that it will accomplish these objectives. It also explains many of the key provisions in the legislation and how they will affect both physicians and patients. Despite considerable uncertainty about the effects of this act, when compared with the status quo, it is an extraordinary achievement that will continue to evolve through its implementation.

Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians

In 1995, the American College of Physicians issued its first statement that raised concern about the epidemic of firearm violence in the United States and advocated for policies to reduce the rate ...

Assessing the New Medicare Prescription Drug Law

Is the Medicare Modernization Act (MMA) a victory for all of Americas seniors (1) or a sweetheart deal for Insurance companies and pharmaceutical firms and a travesty for senior citizens (2)? The rhetoric about the legislation, which President George W. Bush signed into law on 8 December 2003, reflects the ideological divide that almost led to its defeat. Liberals believe that the benefit is too skimpy and that private insurers will skim off the healthier beneficiaries, driving up the costs of traditional Medicare and undermining it over time; on the other hand, conservatives do not like the establishment of a big new entitlement program (3). To bridge this gap, Congressional leaders designed a bill to attract enough votes from Democrats and moderate Republicans in the Senate without losing the support of too many Republican conservatives in the House of Representatives. They bridged the ideological gap by allowing beneficiaries to keep traditional Medicare with improved benefits, while offering them more choices of private plans. The compromise did not end the debate, and the MMA is a major issue in the 2004 elections. With polls showing that voters do not understand the law, both political parties are trying to exploit the issue. One poll of elderly persons found that 53% said that they understood the law not too well or not well at all and only 14% understood the new law very well (4). The publics difficulty in understanding the legislation is not surprising. It is complex, largely because of 4 decisions made by Congress: By offering beneficiaries a choice of enrolling in private plans or in traditional Medicare with new preventive benefits, Congress adds complexity to the decision-making process for beneficiaries. By insisting that the benefit stay within a

Assessing the Patient Care Implications of "Concierge" and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians.

400 billion expenditure limit over 10 years, Congress had to create a confusing cost-sharing structure to keep costs down. By departing from Medicares policy of providing the same benefits at the same cost to all beneficiaries, Congress introduced complex determinations for assets and income. By prohibiting direct price negotiation between the federal government and drug companies and instead relying on private insurers to negotiate discounts, Congress assures that drug costs and formularies will vary from plan to plan and locality to locality. More Private Plans Effective 1 January 2006, beneficiaries can choose to remain in traditional Medicare and decline drug coverage, stay in traditional Medicare and purchase a stand-alone prescription drug policy, or opt out of traditional Medicare and enroll in a government-approved managed care plan that offers not only comprehensive medical care benefits at least comparable to traditional Medicare but also prescription drugs. Beneficiaries will be able to select coverage from health maintenance organizations or preferred-provider organizations. The health plan choices, called Medicare Advantage, replace the Medicare + Choice program created by the Balanced Budget Act of 1997. Medicare Advantage plans are allowed to provide benefits excluded from coverage under traditional Medicare, such as many preventive services, well adult physical examinations, and vision care. The law increases payments to participating health plans, with an average increase of 6.6% scheduled for 2005. Although critics describe this as a health maintenance organization industry pay-off, the higher payments are designed to prevent a repeat of the troubled history of the Medicare + Choice program, which was hampered by disruptive withdrawals of health plans from the market. According to Medicare officials, 4.6 million beneficiaries participate in Medicare Advantage, out of a total eligible pool of 36 million. Officials believe enrollment will increase as beneficiaries learn more about Medicare Advantage. Other observers believe that the administrations expectations of increased enrollment in private plans are overly optimistic, given the advantages that traditional Medicare offers beneficiaries. Traditional Medicare Improvements Traditional Medicare is a defined benefit programthe government guarantees that expenditures will keep pace with the rising costs of covered benefits. In addition, unlike managed care plans, which restrict patients to receiving care from a network of contracted providers, traditional Medicare gives beneficiaries complete control over which physicians they see. Traditional Medicare has two distinct disadvantages compared to the Medicare Advantage plans: lack of coverage for most preventive services and higher average out-of-pocket expenses. The MMA begins to address some of the benefit shortcomings. Beginning in 2005, traditional Medicare benefits will include a one-time geriatric assessment for new beneficiaries and for diabetes and cardiovascular screening tests. In addition, the MMA funds pilots and demonstration projects that could lead to better coverage under traditional Medicare of services relating to care of patients with chronic diseases. It creates a pilot program to reimburse health plans, physician groups, disease management companies, or other entities for effective management of patients with chronic illnesses. Participating organizations will receive coverage for coordination and management services that historically could not be reimbursed under Medicare and will receive higher payments if they manage costs well. In return, they will be expected to measure and report their effectiveness according to accepted clinical performance measures and accept the financial risk of not achieving the desired savings. The MMA allows the results of these pilot programs to be incorporated into permanent changes in benefits and reimbursement under traditional Medicare. The MMA authorizes another demonstration project to encourage physicians in traditional Medicare to measure and report effectiveness in meeting clinical performance measures for 6 chronic diseases and 3 preventive services to state-level quality improvement organizations. These organizations will help participating physicians redesign their offices to take advantage of the benefits of electronic medical records and other health information technologies and provide yet-to-be-defined incentives to encourage physicians to participate. These studies are important because traditional Medicare is built on a fee-for-service, acute care model in which doctors are paid a set amount per procedure or visit for patients who show up with an acute medical problem, without regard to the effectiveness of the care rendered. The studies, if designed correctly and implemented successfully, could lead to permanent changes in the traditional programs benefits structure and reimbursement practices to reward physicians for effective management and coordination of care for patients with chronic diseases. Payment and Regulatory Improvements The MMA makes improvements in Medicare payment and regulatory policies that benefit physicians and, indirectly, patients by making it more likely that physicians will continue to participate in the traditional program. Instead of a cut of 4.5% in 2004 and a similar projected cut in 2005 due to flaws in Medicares payment update formula, the MMA stabilizes payments to physicians by guaranteeing minimum updates of 1.5% annually in 2004 and 2005. The MMA will substantially increase payments to rural physicians. Bonus payments for physician services provided in some designated areas of health profession shortages will be raised from 10% to 15%. Due process improvements are made in Medicares rules for recouping alleged overpayments from physicians for improperly billed services and in the programs rules for documenting office visits. Higher-Income Beneficiaries Pay More Medicare patientsespecially those with higher incomeswill begin to pay more for traditional Medicare. The deductible and premiums for Medicare Part B, which covers physician services, will be indexed to inflation; beneficiaries with substantial means will pay an increased share of the programs costs through income-based Part B premiums. Out-of-pocket expenses for the drug benefit vary by income and assets. Beneficiaries with incomes above 150% of the federal poverty level (FPL) will pay more for drug coverage and will be exposed to a doughnut holeor coverage gapin their drug benefit, while less well-off beneficiaries who satisfy income and assets eligibility criteria will pay little for the benefit and will be protected from the doughnut hole. Standard Drug Benefit Beneficiaries with incomes above 150% of the FPL will be able to purchase a standard prescription drug benefit for about

Universal Health Care Coverage in the United States: Is It “Slip Slidin' Away”?

35 per month, or

The Road to Health Reform: What Can Physicians Expect Over the Next 4 Years?

420 per year, with a

The Demise of the Affordable Care Act? Not So Fast

250 deductible. After the deductible, the Medicare-approved plan will pay 75% of the share of drug costs until total drug costs reach a limit of

The Supreme Court and the Affordable Care Act: Milestone or Detour on the Road to Universal Coverage?

2250. The standard drug plan then pays nothing until a limit of

Achieving a high-performance health care system: policies and positions of the American College of Physicians.

5100 in total costs, or